Clegg Care Facility

Based on observation and records review the licensee did not comply with the section cited above in 2 out of 5 resident medication records which poses/posed a potential health, and safety risk to persons in care. LPA observed 2 out of 5 residents medication logs not accurately documented for medication which had been administered to 2 residents in care for 3 days. Administrator states they forgot to document the log, and that it would be documented each time medication is given.

Based on observation the licensee did not comply with the section cited above in 3 out of 3 staff/ administrator personnel records which posed a potential health, safety risk to persons in care. LPA observed 3 out of 5 staff files verification of annual training not updated annually for the current year. Administrator states that the training would be purchased today 7/17/2025 and completed.

1569.312(a) Basic services requirementsEvery facility required to be licensed under this chapter shall provide at least the following basic services:(a) Care and supervision as defined in Section 1569.2.This requirement is not met as evidence by: Based on records review and interviews with the facility staff the facility did not comply with section cited above. R1 left the facility unassisted and did not return to the care home. R1 had a fall and then was transported to the hospital. The LIC 602 states R1 was not allowed to leave the facility unassisted. This presents an immediate health and safety risk to the resident in care.

87211(a)(1) Reporting Requirements(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified…This requirement was not met as evidence by: Based on records review and interviews the licensee is not ensuring that incident reports are being reported to CCLD. This posed a potential health and safety risk to residents in care.

87465 Incidental Medical and Dental Care(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication…(3) A record of each dose is maintained in the resident's record...This requirement was not met as evidence by: Based on records review and interviews the Licensee did ensure that resident’s medication record is maintained. This posed a immediate health and safety risk to residents in care.

87411 Personnel Requirements – General(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69This requirement is not meet as evidenced by: Based on observations, record review, and interview the licensee did not comply with the section cited above. The licensee did not ensure that 4 out of 6 staff are receiving initial and annual training. Based on record review, no training for 2023 was documented for 4 out of 6 staff files, which this poses a potential health and safety risk to persons in care. This posed a potential health and safety risk to residents in care.

8. 87555 General Food Service RequirementsThe following food service requirements shall apply...Pesticides and other toxic substances shall not be stored in food storerooms, kitchen areas, or where kitchen equipment or utensils are stored. This requirement was not met as evidence by:This requirement is not meet as evidenced by: Based on observation and interview Licensee did not ensure insulin medication was stored separately from resident food, which poses a potential health and safety risk to persons in care. This posed a potential health and safety risk to residents in care.

87303 Maintenance and Operation(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors…This requirement is not meet as evidenced by: Based on observations the licensee did not comply with the section cited above. The licensee did not ensure that the resident bathroom and the sliding door screen were in good repair, which poses a potential health and safety risk to persons in care. This posed a potential health and safety risk to residents in care.

87405 Administrator - Qualifications and Duties(c) Failure to comply with all licensing requirements pertaining to certified administrators may constitute cause for revocation of the license of the facility.This requirement is not meet as evidenced by: Based on observations, record review, and interview the licensee did not comply with the section cited above. The licensee did not ensure that licensee complies with all licensing requirements during NCC meeting on 11/14/2023; which poses a potential health and safety risk to persons in care. This posed a potential health and safety risk to residents in care.

87405 Administrator - Qualifications and Duties(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.This requirement is not meet as evidenced by: Based on observations, record review, and interview the licensee did not comply with the section cited above. The licensee did not ensure that licensee complied with all title 22 regulations knowledge of and ability to conform to applicable laws, rules and regulations, which this poses a potential health and safety risk to persons in care. This posed a potential health and safety risk to residents in care.

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored:(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:This requirement is not meet as evidenced by: Based on observations record review the licensee did not comply with the section cited above. The licensee did not ensure that residents’ that a record of centrally store prescription of medications for residents were maintained, which this poses a potential health and safety risk to persons in care. This posed a potential health and safety risk to residents in care.

9. 87309(a) Storage Space(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.This requirement was not met as evidence by: Based on observation and interviews, licensee did not ensure that multiple disinfectants and cleaning solutions were made inaccessible to residents in care, which poses a potential health and safety risk to persons in care. This posed a potential health and safety risk to residents in care.

87465(h)(2) Incidental Medical and Dental Care(h) The following requirements shall apply to medications which are centrally stored:(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.This requirement is not meet as evidenced by: Based on observations and interview the licensee did not comply with the section cited above. The licensee did not ensure that resident’s medication was made inaccessible to residents in care; which this poses a potential health and safety risk to persons in care. This posed a potential health and safety risk to residents in care.

87468.1(a)(12) Personal Rights of Residents in all Facilities: Residents in all residential care facilities for the elderly shall have all of the following personal rights: or wear their own clothes; to keep and use their own personal possessions...This requirement was not met as evidence by: Based on record review and interviews, the Licensee confiscated R1's snacks and Husky 75 pieace tool set, which posed a potential health and safety risk to residents in care.

Personal Rights: ..(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(3) To be free from...interfering with daily living functions such as eating, sleeping, or elimination.This was not met as evidenced by: Based on observation and interviews, licensee does not allow resident to go into the kitchen. The kitchen is locked, this posed a potiential health and safety risk to residents in care.

87224(a) Eviction Procedures: the licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required...This requirement was not met as evidence by: based on file review and interviews, the Licensee did not ensure to provide R1 or their responsible party a 30-day eviction letter and/or notice. This posed a potential health and safety risk to R1.

87303 Maintenance and OperationWater supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degree C) or above shall be prominently identified by warning signs.This requirement is not met by evidence by: Based on observation and interview the licensee did not maintain bathroom #2 sink and shower water temperature to be within regulatory range. Bathroom #2 sink and shower hot water measured at 150.3 *F without a prominently placed warning sign present which poses an immediate risk to staff and residents in care.

Based on record review the licensee did not ensure 1 out of 3 resident had a MAR log sheet or CSMDR sheet which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation the licensee did not ensure bathrroms had non-skid mats which poses an immediate health, safety or personal rights risk to resident in care.

Based on observation, the licensee did not ensure there was a working carbon monoxide dectors which poses an immediate health, safety or personal rights risk to residents in care.

Based on record review the licensee did not ensure that 2 out of 3 staff had their annual trainings from last year and any current trainings completed which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review the licensee did not ensure administrator had a TB completed which poses/posed a potential health, safety or personal rights risk to persons in care.